Mock Call-Non-Covered service.

Sandy: Thanks for calling this is Sandy, how may I help you?

Sandy: Which Doctor’s office are you calling for?

James: I am calling for General Orthopedic associates

Sandy: What is your telephone number?

James: My telephone# is 800-999-9999

Sandy: What is the patient’s SSN (social security number)?

James: The SSN is 123-456-789

Sandy: Could you please hold for a moment so that I can pull the patient records?

James: Yes, please!

Sandy: What is the patient’s name and DOB?

James: The patient’s name is Linda Far and her DOB is 11-26-1995

Sandy: What is the DOS you checking for?

James: The DOS is 12-10-2020

Sandy: What is the billed amount on this claim?

James: The billed amount is $150.00

Sandy: Could you please hold for a moment so that I can pull up the claim?

James: Yes Of course!

Sandy: Thanks for being on hold James the claim was denied?

James: Okey may I know the claim received date?

Sandy: The claim was received on 12-15-2020

James: And what is the denial date?

Sandy: The denial date is 12-22-2020

James: May I know the reason for the denial?

Sandy: Claim was denied for non-covered service.

James: Non-covered as per patient plan or provider contract?

Sandy: Non-covered as per Patient plan and the patient plan does not cover OON benefits

James: What plan does the patient have? Sandy!

Sandy: Let me find that James?

James: Okey

Sandy: James the patient plan is Hmo

James: Okey Sandy Thanks for that information, Could you please Fax the eob?

Sandy: Yes what is your FAX#?

James: The fax# is 842-543-6789 and you can put attention as my name JAMES

Sandy: Okey James the fax request has been submitted and it will be received within a day

James: Thanks Sandy what is the claim?

Sandy: The claim is 884455

James: Is there any reference # for this call?

Sandy: Yes James it is 0285

James: Thank you so much Sandy you are very helpful to me today and you have a nice day!

Sandy: Thanks James its a pleasure talking to you and you have a good day.
bye.. bye…

If the patient plan is PPO or POS now what will you do?***

Sandy: Claim was denied for non-covered service.
James: Non-covered as per patient plan or provider contract?
Sandy: Non-covered as per Patient plan and the patient plan does not cover OON benefits
James: What plan does the patient have? Sandy!
Sandy: Let me find that James?
James: Okey
Sandy: James the patient plan is PPO

James: Sandy as per the Patient plan type that covers out-of-network so could you please send this back for reprocessing

Sandy: James yes you are right, let’s make a note of it and send it back for reprocessing
James: Thanks Sandy
Sandy: You are welcome James! ….and I sent it back for reprocess so please allow 15 business days for review.
James: Thanks Sandy what is the claim?
Sandy: The claim is 884455
James: Is there any reference # for this call?
Sandy: Yes James it is 0285
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!

Sandy: Thanks James its a pleasure talking to you and you have a good day.
bye.. bye…

Non-covered as per provider contract****

Sandy: Claim was denied for non-covered service.
James: Non-covered as per patient plan or provider contract?

Sandy: Non-covered as per provider contract

James: What is non-covered in the provider contract?

Sandy: provider is not eligible to bill this service

James: Okey Sandy, could you please hold for a moment I will check some additional information on this code?
Sandy: Okey

Now upon checking the patient history and found the same CPT code under this provider has been paid on different DOS what will you do?***

James: Sandy thanks for being on hold, I really appreciate your patience, upon checking the billing summary of this patient we have received payment for this code under this same provider on different DOS, could you please verify that

Sandy: yes please provide me that DOS

James: It is 10-30-2020

Sandy: Let me check this DOS James, so pls be on hold

James: Okey sandy

Sandy: Sandy at that time on dos 10-30-2020 provider have the same contract but it got paid so let me send this claim back for reprocessing

James: Thanks sandy

Sandy: You are welcome, I sent it back for reprocess so please allow 15 business days for review.
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day.
bye.. bye…

Non-covered as per provider contract and Found payment but rep refused to send for reprocessing what will you do?***

James: Sandy thanks for being on hold, I really appreciate your patience, upon checking the billing summary of this patient we have received payment for this code under this same provider on different DOS, could you please verify that

Sandy: Sorry James we cannot compare claims so I cannot send them back for reprocessing

James: Okey sandy can we send an appeal?

Sandy: yes you can!

James: The appeal address is PO BOX 740805 Atlanta GA 30374

James: What is the timely filing limit for appeal?

Sandy the TFL is 120 days from the date of denial

James: Thanks Sandy what is the claim?

Sandy: The claim is 884455
James: Is there any reference # for this call?

Sandy: Yes James it is 0285
James: Thank you so much Sandy you are very helpful to me today and you have a nice day!
Sandy: Thanks James its a pleasure talking to you and you have a good day. bye.. bye..

Now upon checking the patient history and found the same CPT code under this provider has been NEVER paid on any DOS what will you do?..***

James: Sandy may I get the appeal address for my documentation?

Sandy: Yes the appeal address is PO BOX 740805 Atlanta GA 30374

James: What is the timely filing limit for appeal?

Sandy the TFL is 120 days from the date of denial

James: Thanks Sandy what is the claim?

Sandy: The claim is 884455

James: Is there any reference # for this call?

Sandy: Yes James it is 0285

James: Thank you so much Sandy you are very helpful to me today and you have a nice day!

Sandy: Thanks James its a pleasure talking to you and you have a good day.
bye.. bye…